Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Um, good afternoon. My name is Amar. I'm a, I'm a Max Fax registrar, uh, currently based in the southwest of England, uh, working in Gloucester as an ST six, in oral maxillofacial surgery. Um, so I'm just probably gonna spend the next 1520 minutes or so talking about, uh, maxillofacial surgery, um, abbreviated, er to Maxx or OM FS. And why I think it's such a wonderful specialty. Now, I think Liam's talk on Ent was quite a tough act to follow there, but I'm, I'm, uh, II do think we are a, quite af friendly a bunch and, uh, you know, we, we do, we do enjoy a good laugh. So, uh, uh, I intend to sort of convince you all, uh, to consider a career in Mafa over the next 1520 minutes. I'm happy to sort of accept any questions as we go along. Uh, next slide, please. So, Max Fax, you know, is, is one of 10 surgical specialties approved by the Royal College of Surgeons, er, and the, um, joint committee of Surgical Training. What's interesting about Max Fax, er, and is unique is that, uh, despite it being a medical specialty the specialist register of which is held by the GMC. It's unique in requiring dual qualification as I'm sure you're all aware uh in both medicine and dentistry. Uh, and there are, there's a very well variety in the, in the paths that people take to enter higher training in LM FS, whether that's um, medicine first, which has become a lot more common in recent years or indeed, er, dentistry first, which is a more kind of traditional path that people follow into Maxx myself included. So, um there's a very wide scope of practice within, within um within the specialty and you're expected to treat conditions, requiring expertise from both professions, the medic medical profession, as well as the dental profession and that's gonna become a bit more apparent over the course of our talk. Um again, very wide scope of practice. Uh We deal with, er, we probably one of the only surgical specialties that deal with a combination of soft tissues and hard tissues, uh reconstruction as well as trauma and we look at all of these in a bit more detail. Um uh and I think it's important to highlight that there are excellent training and long term job opportunities in RMF S with uh the lowest competition ratios in the whole medical profession, er, um, er, for the last recruitment cycle, I, I'll talk about that in a bit more detail as well. Uh But first of all, we'll just talk about uh we we just kind of review a little bit of a brief history of Maxx, uh, as a specialty next slide, please. So, uh, oral macular fal surgery, er, has its roots within the dental profession. Er, you'll, you'll, I'm sure you, you'll all be aware. Um, it originated in the UK, er, as a, as a surgical specialty of, of, of dentistry, er, developing from the need for specialist services to treat jaw, er, injuries sustained er by servicemen during the, the, the two world wars, er, prior to this facial trauma was, was, was, was, was a bit of a sort of, you know, um um it, it, you know, there was no, there was no distinct specialty that managed facial trauma. Uh it was either managed by a combination of plastics ent or general surgery at the time. Uh and then uh after the start of the National Health Service or I suppose the, the inception of National Health Service Services in 1948 uh a group of or a bunch of ambitious dental surgeons expanded their role from um from dental extractions and minor oral surgery, er to the treatment of more complex jaw fractures um with wires and dental appliances, um which, which sort of uh almost developed into, into, into sort of what we recognize AAA as max factors of specialty. Nowadays, the rise in motor vehicle use and interpersonal violence, um er sort of fed into this as well. Uh eventually evolving into into, er, oral maxillofacial surgery from the original oral surgery as a dental specialty. Having said that O FS remained as, uh, as a singly sort of qualified, um, specialty, er, until, um, until well into the 19 eighties, um, I think, you know, it wasn't until, um, until the late 19 eighties that, uh, dual qualification became a requirement for training or higher training in maxillofacial surgery. Um, and the specialty of Omus evolved to, to meet sort of this increased demand. Um, uh, you know, w which kind of, which, which was me with an increase in prevalence in civil and facial injuries. Um, not just obviously originally from war times, but also in Peace Times. Um, I think, er, owing to the sort of increasing influence of the specialty, er, there was, there was a, a, um, er, once dual qualification, um, became mandatory in the 19 eighties, it was, it was apparent that, er, basic sort of dental training alone wasn't sufficient. Er, neither was basic medical training and, uh, a need for, um, uh, for AAA, need for a, for AAA comprehensive general surgical training as well as a medical and dental training, er, became apparent and, and that's what sort of led us towards, uh, max as we know it today, it was formally recognized as a, as one of the nine surgical specialties. Uh, now, obviously 10, um, uh, pediatric surgery haven't been added to the four in, in recent years. Uh, and it's become, uh, sort of, it's evolved in more recent years into the leading head and neck cancer specialty. Um, within surgery. It's worth bearing in mind that oral surgery as a, as a dental specialty still exists, er, that's sort of, er, a specialty where, where treatment is largely confined to intra oral work. Er, and it all will also falls within the remit of oral maxillofacial surgery and what we do as duly qualified maxillofacial surgeons. Next slide, please. So, um, what does an of surgeon do there? There are a number of subspecialties within of similar to uh what Liam was, was mentioning in his ent talk. Uh, we've got a very wide remit, there is a huge var variety of what we do. Uh, and much of what we do has a very positive impact on the patient's quality of life, which, which makes it a particularly exciting specialty to work in. There are 11 subspecialties within oral and maxillofacial surgery. Uh, some of which require post t fellowship training, many of which don't. So, you know, um, there is this sort of, uh, I suppose, somewhat old fashioned uh attitude towards Maxx being quite a long training uh pathway. Uh, but I'm gonna sort of try and quash that, um, that idea because, because, you know, uh because that's not necessarily the case, um, you know, and people are, are often going off to do post CT fellowships in addition to dual qualification. Uh, and higher surgical training. So, um, head and neck, er, surgery, er, similar to ent ablative and reconstructive. Uh FS is one of the only specialties where we do our own ablation, which means to remove or to resect the tumor. And the reconstruction normally by microvascular means uh skin cancer surgery, uh which is, which is uh the management of um um of facial skin cancer o of all of all different types, management of facial uh, trauma or trauma to the maxillofacial skeleton, orthognathic surgery. Um, a, a form of deformity surgery again which I'll, which I'll talk about in a bit more detail. Craniofacial surgery which largely evolves around management of um, of syndromic, uh deformity, salivary, gland surgery, cleft, lip and palate. Um, one of, one of, one of several, er, specialties that were involved, er, or potentially involved in the surgical management of cleft lip and lip and palate, whether that's primary or secondary primary being in the sort of in the early phases of life, secondary being corrective surgery a bit bit later on in life, er, aesthetic surgery, um, er, to the face, um, or, or, or, or the head and neck sort of region, er, temporomandibular joint surgery as well as uh dental ovular surgery and oral medicine, which are sort of traditional dental specialties of which we have a, a heavy, heavy involvement, um, with, I think, um, we'll discuss all of these in a bit more detail and just to give you a flavor of what an of surgeon does day to day and to demonstrate this kind of very wide remit and breadth of practice. Um Arguably one of the most the broadest within a surgical specialty. Uh Once again, combining both hard tissue and soft tissue components. Next slide, please. So, uh moving on to head and neck, uh which is the surgical management of oral and oropharyngeal cancer uh or O MF. Um uh as it stands is, is a leading specialty in the management of head and neck cancers in the context of the multi. Uh as I say, we resect and reconstruct uh and are often doing the same, well, frequently doing the same thing on the same operation. Um You can see on the, on the left side of the screen, there is a sort of a tumor that's been resected uh from the floor of the mouth as well as uh through the same sort of uh access and neck dissection. Uh And on the right of the screen, you can see a, a radial forearm free flap um which is a frequent, frequently used form of free tissue transfer that we use to reconstruct defects in the head and neck. Um er the um these free flap anastomose through microvascular techniques to recipient vessels in, in the neck uh to reconstruct the defect. And this has revolutionized the management of head and neck cancer. So, this is something that we do on a on a regular basis, er, myself, um I'm involved in sort of at least a case a week if not too sometimes. Um, and it's, and it's, you know, made a big difference to uh to quality of life outcomes er, in head and neck cancer. Uh Next slide, please. Thank you. Er, so moving on to skin cancer, er, treatment. So this is, er, so skins as it sort of, er, fondly referred to in max fact is the management of Melanoma and non Melanoma skin cancers. And this involves the excision uh of of, of uh of lesions, skin lesions and the reconstruction with a combination um of local flaps, uh primary closure or with full thickness skin grafts or split er split thickness, skin grafts depending on the size of the defect. So you can see on the left of the screen there, something called amylo labial uh uh flap, which is a form of local flap. The resection er um site is just on the kind of left ale of the nose you can see there. Uh and there's a flap which is an inferiorly based uh flap based on the blood supply and a pedicle further down that's been drawn up into the defect. Um and, and the the almost almost like a av to Y closure further down along the neon la crease um leading to quite a sort of an acceptable uh I would say aesthetic result um on the right of the screen at the top there again, a defect along the, along the sort of uh the, the, the, the nasal cell or the, or the margin of the ala on the right hand side, reconstructed with something called a bilobe flap, which is where you have a pedicle, er, more superiorly based and you've swung into the defect, er, to reconstruct again. Uh you know, you see these patients a few months down the line and they've got a very acceptable aesthetic result uh further down um uh sort of a. So, so, so the image sort of on the right hand side at the bottom there er is er of an sec that was excised from the vertex of this gentleman's scalp. Um and er has been reconstructed with something called an O to Z flap. So you can see it started off as you know, a number of kind of Z um er extensions uh just adjacent to be able to almost bring it together like a camera shutter if you like. Um um with once again, a sort of a very acceptable aesthetic result, this can be very, very complex surgery sometimes. And uh it relies on a heavy interface with, with um our dermatology oculoplastic colleagues, colleagues, sometimes in ophthalmology as well as our ent colleagues next slide, please. So, moving on to the management of trauma to the facial skeleton maxillo, facial trauma. This is a combination of soft and hard tissue trauma. Uh This can be anything from a, from a, from a laceration, a simple laceration or a complex laceration. Uh um So, varying complexities and we're often the first point of contact from emergency departments for facial lacerations and that and that's the case up and down the country. Uh In fact, um all the way to complex pan FCI trauma and complex pan fal trauma um could be, you know, patients that were victims of interpersonal violence uh or road traffic collisions. Um and requiring sort of comprehensive facial reconstruction, these can be all day cases that we get involved with. Um and going back to why we sort of, we require a dental qualification as well. Um Many er principles of dental occlusion are employed in management of these cases. So, um you know, hence the need for the dental background, 11 example of, of, of, of um of why it's why it's required um um and a, a huge amount of discipline um sorry, development has um taken place within the discipline of, of maxillofacial trauma. And there's a lot of virtual planning nowadays. Uh knowing exactly where you're gonna sort of place your plates, prevent plates for reconstruction of the maxillofacial skeleton, intraoperatively, the use of CT guided on table navigation for reduction of fractures. Um and, and all that sort of thing. So, so, you know, it's, it's, it's, it's, it's moved on quite considerably. So you can see on the left of the screen there that sort of um that cartoon image of uh of a reconstructed uh maxillofacial skeleton. Uh number of fractures. There you can see there are fractures to the frontal bone fractures to the orbits, the er Zygomaticomaxillary complex as well as the, the, the mandible. Uh and these are access to a combination of uh of intraoral incisions, extraoral incisions, eyelid incisions as well as a coronal flap, particularly for, for, for, for injuries involving the frontal table of the um sorry, the anterior table of the frontal bone typically accessed with uh what you can see in the second image in the middle of the screen there, which is something called a bicoronal flap on the right of the screen there. You can, you can see at the top er that's er the a typical uh sort of a mandibular fracture that I would um I would be managing on, on a, on a sort of almost weekly basis. Um And the use of of mini plates technology, a titanium mini plate technology um with, with screws has kind of revolutionized the way that we treat these fractures. Once upon a time, they used to be a wired shot for six weeks. Now, now they can go off um you know, on, on a fairly soft die and uh and things seem to be a lot, lot easier for them. Uh And some uh uh ju just, just um uh the image just, just be beneath that on the screen and you can see a, a laceration uh that, that young lady come to A&E with a, with a facial laceration just above her, her right eyebrow. Er, and it was, um, and it was uh sutured and enclosed uh at the time of, of presentation. Uh and you can see quite a sort of acceptable aesthetic results. Um several months down the line that next slide, please. So, um moving on to orthognathic surgery, which is sometimes referred to as uh as deformity surgery. This is a typically a joint surgical and orthodontic approach. So where we um we sort of um manage these very closely with our, with our dental colleagues who are specialists and orthodontists. Er and they typically involve a controlled fracture to the mandible or the maxilla or bother to reposition. Um both of them producing a favorable aesthetic uh or functional result. Uh And again, this discipline relies very heavily on the principles of dental occlusion, uh which is a sort of a science in its own, right. Um that you that you go into in a lot of detail as a, as a dental undergraduate and postgraduate. Um these cases are typically um traditionally, I should say planned manually using study models, uh impressions of, of, of the jaws that are taken sort of on the clinic. But there's been a move towards virtual planning more recently. And that again has revolutionized the way that we um approach these cases interoperatively. So you can see uh sort of at the top of the screen um uh on the right hand side, er, that young man has what we refer to as a class three malocclusion, er, and skeletal uh uh deformity where the bottom jaw is sort of, er, is very, very pragmatic. And in those cases, we would do a combination approach where we do a um a controlled fracture of the, of the, of the maxilla uh in the 41 as well as a controlled fracture of the mandible, a bilateral sagittal split osteotomy. And that's brought back in sort of a combination of both moves with a, with, with a sort of, with an element of pre surgical and post surgical orthodontics will, will um produce quite an acceptable uh or, or, you know, um um optimal uh aesthetic results. Um the, the, the, the, the, the, the, the young lady at the, at the bottom of the screen on the right hand side there. Er, you can see she had something called uh significant vertical maxillary access, which is where on smiling there is a, a fair bit of sort of gum, gummy gummy show which to a lot of people. Um they, they prefer not to, not to have to, not to have it. It can have a, a real sort of impact on, on their, on their bites and their occlusion as well. Uh And you can, you can do impaction procedures of the maxilla to, to um to improve both function and appearance er in those situations. Uh Next slide please, uh moving on to craniofacial surgery. So this is surgery for the management er of syndromes and their associated deformities. Er, typically working within an MDT um uh closely with our neurosurg surgical and plastic surgery colleagues. And this involves the treatment of conditions such as craniosynostosis, hemifacial micros treat common syndrome um and um and vascular malformations in the head and neck region. And it employs the use of various osteotomies, er and destruction osteogenesis techniques uh to correct congenital deformities as you can see on the screen there. So the images here uh are of a um um of a girl with Croon syndrome before um and after surgery. Next slide, please. Uh moving on to salivary gland surgery, er which is the management of salivary glands, pathology. Another subspecialty of oral and maxillofacial surgery. Um and this involves the management of both benign and malignant tumors. Uh parotid benign tumors such as pleomorphic adenomas being the most common ones that we deal with uh stones. So, uh salivary gland or duct stones, we see a lot of and, and uh forms a very large proportion of the workload. Um and we often do open surgery, excuse me in these situations as well as er s endoscopy, which is, which is an endoscopic technique as you can see on the right side side of the screen. Uh and you can, you can dilate ducts, er, so, um, narrowed, narrowed sort of, er, er, ducts as well as basket retrieval of stones that maybe, um, and maybe blocking, blocking, uh uh, blocking the outflow of saliva and patients often in terms of quality of life. Uh, it, it makes a massive difference. They, they have an almost instant relief of symptoms. Um, on the left side of the screen there, you can see something called a modified Blair approach uh for a procedure called a superficial parotidectomy. I know Liam mentioned, mentioned that in his ent talk. Uh it's something we, we, we do a lot of as well. Um It's, it's a technique that's still, er, quite commonly used for management er, of er, benign parotid lesions. But more recently, there's been a move towards a more conservative technique called an extracapsular dissection. I'm not gonna go into too much detail about that essentially, you know, forming with falling within the remits of salivary gland surgery. Next slide, please. Cleft lip and palate er, is another subspecialty of oral and maxillofacial surgery. It's a complex one gen generally requiring post ct fellowships to gain the skills needed uh for optimal patient patient outcomes. Um, it can be sort of divided up into primary cleft surgery as well as secondary cleft surgery. Um, so in the primary being in the first few months of life, um and secondary, er, it tends to happen a bit later on in life. Examples, includes definitive orthognathic surgery, um septorhinoplasty. So, nose jobs essentially uh alveolar bone grafts, uh which is taking bone from different parts of the body normally and iliac crest to reconstruct any missing bone in the, in, in, in the maxilla, uh which is a common uh common finding in cleft lip and palate cases. Um, plastic surgery is a specialty that's also very heavily involved in cleft palates, uh cleft lip and pallet surgery. Uh and it, I would say cleft lip and palette probably straddles plastics as well as Maxx, but it's something that you can certainly train in as a maxillofacial trainee. Um And you can see sort of some before and after results are on the screen. Uh Next slide please, aesthetic surgery. Um is another uh uh subspecialty that falls within the remits of f er, facelifts and all of its variants, things like rhinoplasties, uh and blepharoplasties, upper and lower lids, uh non surgical and injectable facial aesthetics, very sort of topical nowadays. Uh I'd say FS is probably best placed uh to provide these services due to a very detailed knowledge of the facial anatomy, owing to, to sort of two degrees and qualifications. Uh I'm thinking nowadays, unfortunately, it's a little bit of a free for all. There's, there's not really all that much regulation of the industry. But, um I would say with time, certainly, you know, um it, it, it, it may well become a lot more regulated. Uh and as a musculofascial surgery. You're very well placed to provide these services, uh, picture on the left. You can see, uh, a lady had a facial rejuvenation, uh, with a number of procedures, uh, something called a sma facelift as well as upper and lower legs, blepharoplasties, um, uh, and a platysmaplasty for the neck creases. I suspect she's probably had some injectable fillers and Botox, um, uh, in, in various places that could sort of, um, that will have led to, to sort of uh her results and I'm pretty sure of the right, slightly more subtle results but more frequently requested by patients. Nowadays, uh, next slide please. Um moving on to TMJ surgery. So, temporomandibular joint surgery, this is, these are sort of fair, fairly complex er, procedures. Um uh it's a very complex decision with quite complex decision making. Um often cases of severe internal internal derangement within the joints, degenerative change, er, which is severely impacting patients quality of life, they're unable to open their jaws or eat or talk. Er, and um, you know, the, the treatment of these patients could involve anything from fairly conservative management such as advice, analgesia, the use of physiotherapy, um Botox to muscles and mastication or all the way over to, to sort of open TMJ surgery with the most complex form being a total open TMJ replacement as you can see on the screen. Now, next slide please. Um, finally, dental alveolar surgery and oral medicine are two specialties that uh have roots very much within the dental profession, but we are quite heavily involved with. Uh, and in fact, form quite a large bulk of our workload day to day. Uh, dental ovular surgery is probably just another term for oral surgery, which is intra oral surgical work. Um There are dental specialists in both of these, uh both of these disciplines, both oral surgery and oral medicine. Uh Both of which are their own kind of separate training pathways. Um A and the specialty lists of which are held by the General Dental Council by the General Medical Council. However, as maxillofacial surgeons, er by virtue of our training, uh we are also by default, specialists in both of these fields. Uh cases include things like surgical removal of third molar wisdom teeth, the surgical management of cysts within the jaws, uh and the management of oral mucosal lesions, lumps and bumps, lichen planus, candidiasis, ulceration of the oral cavity and oral medicine can be quite a complex um field in its own right. Um Next slide, please. So, um er sorry about the er busy slide, it's a bit of an old fashioned uh infographic demonstrating the two main training pathways in of dentistry first and medicine first. I think there's a lot more people nowadays going into O MF from a medicine first background. Uh and this is traditionally a shorter route, the dentistry um for a numer dentistry first, for a number of reasons if I could perhaps just spend a minute talking about this. Um, so there are a number of three year dental degrees post F two, which are sh shortened. Uh, you can do the MRC S as a second degree student with many doing this um, er, during their second degree dentist history. First, um, candidates are expected to do something called the MF DS, which is a dental cousin of the MRC S as well as the MRC S when they qualify as doctors. Um And I think it's worth noting that you can apply to start ST one and Maxx or run through uh CT one after completing a three year degree. Uh There is also the advantage of being able to skip the ST two year, uh and CT two year if you have passed the MRC S. Um and that's not an option in other surgical specialties in addition. Um I believe that the only other surgical specialty, uh that's where training ends at the ST seven level is urology. Maxillofacial surgery does not require you to do an ST eight year uh perhaps owing to the length of training. Um And that I think is another advantage of Maxx access to specialty next slide, please. So, uh coming, coming close to the end, I'm, I'm sorry, this is taking quite a while. How am I doing for time? Am, am I sort of over? Uh Yeah, they're running a little bit over. Are you happy to just, um, sum up a little bit. Yeah. Ok. Yeah, we do. Sure. Um, just, just sort of, um, just very briefly about this sort of length of training. Uh I think, you know, um, there can I get you to move on to the next slide after that one? Yeah. J just kind of, these are kind of some scree screenshot, er, slide before I think, slide before that one. That's the one. Thank you. Yeah, so these screenshots are taken from the R CS er England website. You can close the very, very low competition ratios for all the maxillofacial surgeries, 0.7 applicants per year uh in the last recruitment cycle. Um and um the low light on call commitment is highlighted specifically and that's a big sort of bonus with the Maxx. Next slide, please. Number of shortened degrees, as mentioned, I won't go into them in any sort of detail, but, but I'm happy to be contacted about those personally next slide, please. So uh in terms of quality of life, er very light o on calls compared to other surgical specialties, both at registrar and consultant level, er spr on call tends to be nonresident myself most recently, you know, um I'm, I'm, I'm often sort of at home uh very rarely have to go in unless there is something uh urgent and that doesn't seem to happen all that often. Um There are, there is a fair bit of private earning potential. Um which again, I don't really need to go into, into, in that much detail. But owing, owing to your dual qualification, you have potential options to provide private practice in both professions. Uh and job satisfaction is widely considered to be very high. Uh Next slide, please. Um We're all very happy uh to have keen and interested trainees. Uh And there's a strong tradition within max facts of supporting juniors to pursue a career in the, er, in the specialty. Happy to be approached. Uh, just a final plug before I sort of, um, um, before I log off, uh with regards to the preconference, uh trauma management Max Fax workshop uh at the A, a conference which is gonna be in Belfast in early March 2025. It's a good opportunity to connect with the registrars and consultant in the specialty. Um, and we'd be more than happy to see you there. It's a, it's, it's a really good opportunity um to sort of get hands on with what we do in Maxx. And I know of a number of people that have sort of uh taken an interest in the specialty after attending the, um, the preconference uh workshop. Thank you. Sorry, I, um, I went over a little bit there. No, don't worry at all. Thank you so much for delivering that talk. Um I'm starting to have second thoughts now and I think I need a taste a week in Max Max. Um And I'm sure that we've got a number of attendees thinking the same. Um We don't have any questions, but I think we've over run a bit so we don't really have time for many questions. But um hopefully you guys took a screenshot. I think some of these slides may be made available if, if uh speakers provide consent that that will be discussed at a later time. Um So, yeah, thank you very much for your time being here today. I really appreciate it and I'm sure you've got probably a or two new max trainees for the future. I hope so. Thanks for your time. Thank you very much. Enjoy your day. Thank you. Yeah. Thank you. Bye bye.